If you’re a physician, the CT scan above ought to get your attention….but more on that later.
A lot of people (well, doctors mostly, but they, too, are people…mostly) want to know what’s it like to practice medicine in a different country. So this week I thought I’d share a typical day of my work at the hospital.
I should first mention, we don’t have any COVID cases in the hospital. Actually, not even any COVID cases in Dunedin. And to be fully truthful, for two straight days none in the whole country. That’s just a little different than what I would be experiencing in California. Just a little…
I’ll walk you through a typical ‘on call’ day…which means I’ll be accepting patients for admission to the hospital beginning at 8am and ending the following day at 8am. I arrive at the hospital a little after 7am. My office is on the 7th floor, but given that the ground floor is street level (what in the USA would be the first floor), I have 8 flights of stairs to ascend. It’s a good way to start the day.
It’s a good thing the cardiology department is also on the 7th floor, as I’m sure one day I will experience some chest pain during the ascent.
Did I mention there were no COVID cases in NZ?
When I arrive to my office, I’ll review the events of the last 24 hours, and then proceed to our 8am handoff meeting, where all the patients admitted over the last 24 hours are reviewed and assigned to the relevant teams. I then round (or go see patients) with my team…which consists of a registrar (kind of like a senior resident in the US, though my registrar has many years of training under his belt), a house officer (who is in her third year of postgraduate training), and a medical student.
During the day, we will see the patients who need hospital admission to the internal medicine service. The variety on conditions we see is legion, and you never know when the operator calls to connect you to someone what you might encounter on the other line. Like, in the case of last Tuesday, when the operator connected me to a physician from a rural hospital about 150 km outside of Dunedin. A patient had come to the hospital with visual disturbances and new mild right sided weakness. The CT scan there looked similar to the one above (which I pulled from the internet to preserve patient confidentiality). I asked some pertinent clinical details, and since we have a neurosurgeon on staff here, agreed to have the patient transported here for further evaluation and possible intervention. The transport would be a helicopter, which is a common mode of transport to this hospital (I think helicopters transport patients here at least 4-5 times a day…we have a helicopter pad at the hospital I worked at in California…it is not used nearly as often…like 4-5 times a year).
It wasn’t a long a wait for the patient to arrive in Dunedin…maybe 2 hours since the phone call…and in that period the condition of the patient had worsened. We arranged another CT scan of the brain, which confirmed our clinical suspicion of further bleeding and worsening edema of the brain. We talked with the neurosurgeon, who felt there was already significant damage to the brain, and the surgeon was of the opinion that even with an operation there would still be significant functional impairment. To translate that, at best, the patient would be completely paralyzed on the right side. We then discussed this with his family (by phone, as they would be driving here and wouldn’t be here for an hour or two), and they informed us that if we felt the outcome was unlikely to be significantly better with surgery, since the patient had previously been very clear that any significant physical impairment would not be acceptable, to not proceed with any surgery.
My registrar diligently cared for the patient that night…and we all met together the next morning with the patient (who was not responsive…read- not awake-) and the patient’s whole family…the spouse, sons, daughters, and grandchildren.
I should reiterate, again, we don’t have any COVID patients in the hospital, in case you had forgotten.
Back to my patient now…
The patient’s condition had worsened mildly overnight; we had tried some medical therapies to decrease swelling in the brain, with only modest effect. We had lengthy discussions with his family throughout the day and the family was very clear the patient would not have wanted any life prolongation measures in this particular circumstances, and would just want to made comfortable. So that is what we did, and very quickly after that, the patient passed away.
I met with my team at the end of the day, because it was not clear to me they truly appreciated all that had happened that day. We gathered around, and reviewed the clinical events; a patient with long-standing high blood pressure presented with an acute intra-cerebral hemorrhage (bleeding in the brain), which was too severe and in a location which was not amenable to surgical therapy. He died of this acute event. That information we all understood, but what was so unique for me was that I have never experienced the kind of discussion with a family about an acute, devastating event that occurred that day. In fact, the words to my team were, ‘in the 34 years I’ve been practicing medicine, I have never had a family discussion like that…..ever’.
What made this discussion different for me (and keep in mind my registrar has been here in New Zealand for 4 years and he didn’t bat an eye during the discussion) was how sincerely nice every single member of the patient’s family was during this devastating event. I remember explaining to the family what had likely happened to cause the bleeding. They acknowledged the patient had high blood pressure, that these things (like bleeding) can happen, and that we all are going to pass away sometime. Those were the families’ words. They appreciated (and they said that several times) that we seriously considered trying to do surgery (the acute helicopter transport to Dunedin and a thorough review with the neurosurgeon) and they accepted the outcome with surgery would have likely been not what the patient had wanted. In these conversations, my accent (clearly not New Zealand) came up…they thought I was from Canada. We all laughed as I tried to distance myself from the fact I was from the land of the President who shall not be named. We talked about water polo, since one of the patient’s granddaughters had a water polo sweatshirt on…we talked about the life the patient had with his spouse of about 40 years. We cried at the sadness of a life’s end, and we were also thankful for the lack of prolonged suffering and disability. There were hugs all around, several times during the day. This was a brief illness, and a brief encounter in the scheme of things for me… less than 48 hours…but it was an encounter I will never, ever forget. And this was just my first full week working in the hospital, and I suspect there will be more encounters like this.
Oh yeah…there are no COVID cases in NZ.
There are struggles working here in New Zealand, just as there are struggles working in any hospital, anywhere. But if you wonder what’s different here…what’s truly different here…it’s the people.
Be well, remember that life is short. If there is someone in your life you love, tell them today.